Cleveland State University
EngagedScholarship@CSU
Cleveland State Law Review
Law Journals
1958
Psychosomatic Disease and the Law
Carl E. Wasmuth
Cleveland Clinic Foundation
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Recommended Citation
Carl E. Wasmuth, Psychosomatic Disease and the Law, 7 Clev.-Marshall L. Rev. 34 (1958)
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Psychosomatic Disease and the Law
Carl E. Wasmuth, M. D.*
T
HERE ARE FUNDAMENTAL DIFFERENCES
between the standard of
probabilities in law upon which a jury must deliberate, and
the standard of certainty in the scientific laboratory of medicine
which an investigator must respect. It is frequently stated that
no common grounds exist upon which a mutual understanding or
agreement of these fundamental variations can be reached.
This conflict often is the result of a lack of mutual understanding and respect of the basic ground rules of both professions. The physician resents the lawyer's obviously scanty knowledge of things medical and his attempt to refute competent medical testimony by legal maneuvering. The attorney deplores the
hesitancy of the physician to depart from the principles of the
scientific laboratory and his adamant refusal to accept the legal
definitions and principles of causation and measures of damages
in their application to the case in law.
This conflict is nowhere more evident than in the field of
psychosomatic disease. This area of medicine has long been recognized but it was only in recent years that it has become the target
for intense research. This lack of medical interest in what was
considered a fringe area has caused the legal profession to substitute law for medicine. Eventually, however, science will
progress in the field of psychosomatic medicine to the point
where the lawyer will have accurate, objective tests available to
show causation and to evaluate the extent of damages.
Very early in his academic career, every law student briefs
the case of Lynch v. Knight, where Lord Wensleydale stated:
"Mental pain and anxiety the law cannot value, and does not pretend to redress, when the unlawful act complained of causes that
alone." By this statement the English court simply ruled that
pain and suffering were difficult to prove, and that it was present
it was impossible to assess by other than subjective tests, and
that unless there was physical injury, damages for mental pain
* Member of the Staff in the Department of Anesthesiology of the Cleveland
Clinic Foundation; B.S. and M.D. from University of Pittsburgh; Fellow of
the American College of Anesthesiology; Diplomate of the American Board
of Anesthesiology; and a third year student at Cleveland-Marshall Law
School.
[ILLUSTRATIoNs are at the end of this article.]
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and suffering would not be allowed. The court thereby took legal
cognizance of the lack of scientific objective tests for evaluation
of mental pain and suffering. The plaintiff in many deserving
cases was denied damages for mental and emotional trauma because of lack of scientific corroberation.
A still larger and vastly more complex field involves the
causation and extent of injury resulting from psychic trauma.
Medical testimony here frequently must be based on medical
judgment. Hard scientific evidence often is impossible to find or,
if found, is impossible to apply. Inasmuch as the docket of most
courts today is overwhelmingly laden with personal injury cases,
the extent of damages for the immediate injury and its sequelae
looms ever greater. Determination of causation of disability and
pain and suffering resulting from precipitation of disease or aggravation of pre-existing disease is a most perplexing problem.
Elsewhere in this issue of this Law Review an article [Relation
of Trauma, Disease and Law-A Symposium] points up this
problem with great clarity. Suffice it to say that today physicians
are taking medical note of a fact which the lawyers recognized
many years ago-that the body is a whole, and that injuries of
one part may affect the entire organism. Our brethren in the law
have for many decades been seeking redress for mental pain and
suffering in tort actions. Inasmuch as they had no objective tests
with which to verify psychic trauma, damages were frequently
denied.
In recent years, however, medicine has taken a greater interest in this field of mental pain and suffering. It is recognized
today as a distinct clinical entity and is known under a variety of
terms such as stress reaction, psychoneurosis, postconcussional
syndrome, and many other terms relating to the specific disorders
of individual parts or organs of the body. All of these various
names and subdivisions can be grouped together under the general term, phychosomatic disease. As the name points out, this
specialty of medicine deals with the interreaction of the brain
and the central nervous system with the soma or the remaining
part of the body; not included are the purely psychiatric conditions such as the psychoses.
Physicians have known for many centuries that the emotions
play a predominant role in disease. However, with the specialization in medicine, many have lost sight of the body as a whole and
tend to separate the psyche from the soma. The country doctor
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and the general practitioner of medicine recognize only too well
that injury to the body is reflected immediately in the central
nervous system and that both require treatment. In fact, many
times the psyche is in far greater need of therapy than is the
diseased body. Many describe the complaints related to the emotions as functional; some state "it's in your head." No matter by
what label it is tagged in medical nomenclature or practice, the
patient is no less sick and in need of treatment. However, it took
the laboratory scientist and the specialist to reduce the empirical
claims of the general practitioner to concrete medical facts.
Psychosomatic disease also includes that great mass of conditions of patients whom the internist treats for chronic illnesses.
It is upon these patients with chronic disease that the psychic element of trauma may have devastating influence. They already
are suffering from disturbances in their emotional lives. The illness may be wholly or partly of psychological origin, and can be
satisfactorily studied and treated only if this factor is adequately
appreciated. It matters not whether the emotional factors are
initiated by a diseased organ or by the trauma of an automobile
accident. If the personality is sensitive enough, a comparatively
minor episode may be the precipitating factor for a psychoneurotic or psychosomatic illness. Among individuals, the sensitivity of the central nervous system to this type of illness varies
as greatly as does the susceptibility of the soma to infection. To
understand the modus operandi completely, it is necessary to review some of the anatomy of the nervous system and its control
of the body.
Anatomy of Central Nervous System
The central nervous system has two major divisions: (1) the
somatic nervous system, and (2) the autonomic nervous system.
The former primarily is the source of our intellect, our five senses,
and our control of the voluntary, skeletal muscles of the body.
It consists essentially of the brain, spinal cord, and peripheral
nerves. The most significant item, however, is its conscious control of the voluntary motions of the body. The cortex or outer
layer of the brain is the center of higher intellect. Most highly
developed in man, it controls every conscious movement of the
body. It receives pain, touch, and temperature sensations from
the distal limb over the sensory (afferent) nerves and registers
them in the higher centers. The brain then interprets these sen-
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sations and causes a reaction over the motor (or efferent) nerves.
Sight, taste, smell, and hearing are mediated over the cranial
nerves.
This discussion is mostly concerned with the autonomic
nervous system, sometimes referred to as the vegetative nervous
system. In contrast to the somatic (or peripheral) nervous system, this system controls the internal organs of the body, the
blood vessels, sweat glands, pupils of the eye, secretory glands,
some endocrine glands, reproductive organs and sphincters of the
rectum and bladder. At a glance, it becomes evident that we
seldom are conscious of the sensations of these organs and that
we have little or no conscious control over them. This, in brief,
is the autonomic nervous system-a complex control mechanism
which is constantly directing and influencing the functions of the
body such as digestion, breathing, circulation, excretion and
sexual activities.
Upon closer examination, however, we find that physiologically this system actually is divided into two components, the
function of one being counteracted by that of the other. The
sympathetic nervous system and parasympathetic nervous system
together comprise the autonomic nervous system. As a general
statement, where the sympathetics stimulate an action, the parasympathetics inhibit the same action; and vice versa. Where the
sympathetics relax, the parasympathetics close a sphincter. This
opposing action, however, is finely balanced. In the state of inactivity, on normal rest, both systems exert simultaneous influences over muscles, resulting in normal muscle or sphincter
tone. When that organ, sphincter or muscle is needed for a specific body function, by precise control the one system is inhibited
and the other system stimulated and the function is effected:
the stomach begins digesting, the bladder is emptied, or the
uterus contracts to deliver the baby.
This central control of the autonomic nervous system is located in the midbrain, close to the pituitary gland. This part of
the brain is, phylogenetically speaking, a rather primitive extension of the brain stem. It is said to house, among other things,
the emotions, such as fear, rage, disgust, and sorrow.
After due consideration, one realizes that the emotions too
are to some extent involuntary. Who can control fear when an
automobile is approaching at high speed in his lane of traffic?
Who can completely control sorrow when his mother or father
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or wife or child is dying? These basic emotions have been present in the midbrain through many thousand generations of man.
They are, for the most part, involuntary actions, but in varying
degrees in man they are subject to the control of the cerebrum
or cortex of the brain. Some people cry at sad movies, some
laugh easily at poor jokes. Some people are antagonistic, some
are congenial. For the most part these are manifestations of midbrain function and are seated very close to the nuclei which
govern and control the autonomic nervous system. Perhaps we
all remember the child who laughed so hard that she wet her
pants, the man who was so angered that he got indigestion, or
the woman who was so frightened that her heart seemed about
to jump out of her chest. The seat of these emotions is so closely
related to the seat of the autonomic control mechanism in the
midbrain that the one is frequently affected by the other.
Their results are the menstruating woman whom Stewart
calls a "witch," the man with an ulcer burning in his stomach
who becomes a bear, and the baby crying with the colic all night
who brings many otherwise happy marriages to the brink of
divorce. So interwoven are these nervous systems with the midbrain and the emotions, that the effects of one can never be separated from those of the other. An injury or illness to one part of
the body might easily send these sensory impulses to the midbrain. At this point, the emotions might be affected and/or the
autonomic nervous system stimulated in some manner. It may
easily be seen that a severe fright can be manifested in emotional change and also in indigestion, or in involuntary urination.
Perhaps such a fright may also cause a quiescent stomach ulcer
to rupture or bleed or a dormant spastic colon to be activated. Is
the fright the proximate cause?
One can now begin to understand the over-all effect of injury to the body and transmission of the pain sensation to the
midbrain. Emotional effects are dramatic and, if sustained,
establish a pattern that may affect the rest of the body (soma)
through the autonomic nervous system. The question now becomes: When does a normal physiologic reflex become abnormal
or pathological?.
The sympathetic nervous system originates in nuclei of the
midbrain. The nerves run in the spinal cord and emerge
along the nerve roots that are given off at each vertebra. Most
of the sympathetic nerves are distributed to the internal organs
of the chest, abdomen, and pelvis. Others ride along the blood
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vessels to the limbs and brain. The latter nerves supply the
vessel walls and sweat glands. In the chest, the sympathetics
supply nervous control to the lungs and heart. In the abdomen,
the sympathetics supply all the organs of digestion, the kidneys
and blood vessels. In the pelvis, the sympathetics supply the
reproductive organs and sphincters of the bladder and rectum.
Stimulation of this nervous system, therefore, can cause effects
manifested throughout the body.
The origin of the parasympathetic nervous system is more
complicated. The principal and largest part of this system is the
vagus nerve (X cranial nerve). This nerve originates in the
brain, emerges from the skull, and travels down the neck, giving
off numerous branches. When it enters the chest, branches are
distributed to the heart and lungs. When it pierces the diaphragm and enters the abdomen, the right and left vagus nerves
coalesce in the celiac ganglion. From here its numerous
branches supply the organs of digestion and the kidneys. In the
pelvis, the parasympathetics originate not from the vagus nerves
but from the spinal cord. They supply the reproductive organs,
the bladder, and the rectum. Stimulation of this parasympathetic nervous system affects any or all of these organs.
The midbrain, however, is not the true controlling part of
the central nervous system. In order that the thalamic (midbrain) reflexes, such as fear and rage, do not go uncontrolled,
civilized man has built-in in the brain, a supreme governor.
This structure (which we have discussed) is the cortex of the
brain. Developed to its highest degree in the human, the cerebrum is the center of all intellect. It governs what we think,
what we do, and how, when and why we do it. It is the high
court of the nervous system and it sits in both law and equity.
By its consummate action, each of us is an individual with his
own characteristics and behavior patterns. We are not just
thalamic animals exhibiting rage, fear, or sorrow, but individuals
who by reason of the cortex react, modify, and obtain the basic
emotions by way of cortical inhibition. Some of us are refined,
gracious, and meek. Others are dynamic, vulgar, and ambitious.
Each has an anatomically identical midbrain, but the inhibitions
of it, controlled by the cortex, determine the personality. It is
little wonder that Lord Wensleydale threw in the legal sponge
and stated: "Mental pain and anxiety the law cannot value and
does not pretend to redress, when the unlawful act complained
of causes that alone."
A few cases of wet pants, pounding hearts and indigestion
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are certainly not sufficient cause for damages in court. Fortunately from the physical view, and unfortunately from the
legal, these changes while dramatic are not prolonged nor permanent. However, if these changes are present for any length
of time, so that a normal physiologic reflex becomes a pathologic
or abnormal state, we have a disease or possibly a legally compensable condition.
Let us consider in very general terms the condition known
in medicine as the "American Disease." Most Americans live
under conditions which are more or less stressful. Young men
and women, full of ambition and the desire to progress in the
business world, take on the added burdens of attending night
law school. In addition to their usual family responsibilities,
social obligations and classroom attendance, they spend a great
number of hours in study and preparation for examinations.
Sooner or later, such stress begins to show. At least in the
older groups, it would be interesting to know how many have
headaches (migraine), stiff necks, urinary or digestive disturbances, irregularities of the heart, and emotional or personality changes result from this stress. These same studies
have been made many times in the business world. As a result
of them many large corporations require their key personnel to
have routine medical examinations, vacations and daily rest
periods. Comfortable and pleasant dining rooms are supplied,
and the employees are expected to take adequate lunch periods.
By these prophylactic measures, industry has found that it can
keep the American Disease to a minimum. The reaction of the
midbrain to the stress of business worries and obligations is
thereby reduced. The autonomic nervous system during rest is
given respite from the incessant stimulation of the emotional
upheavals. The coronary arteries of the heart are permitted to
relax; the increased and deranged motility and excessive secretion of acid in the stomach return to normal; the spastic gut relaxes; and the pain and distress of menstruation may be relieved.
The effects of stress are the result of the press of circumstances and environment upon the emotions, midbrain and autonomic nervous system. The effects of stress might be from an
injury, from mental strain (pain and suffering) of any cause,
from disease process, or from suggestion. The effects of stress
are manifested in any number of ways or combinations. The
effects may be seen in the emotions, as in any organ innervated
by the autonomic nervous system. The effects therefore may be
in the lungs (asthma and "allergic conditions"); in the heart
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(coronary artery disease, angina pectoris, other irregularities);
in the stomach (gastritis, peptic ulcer, gas, bleedings, butterflies); in the gall bladder (biliary colic, stones); in the gut
(colitis, irritable colon, mucous colitis, regional ileitis, proctitis);
in the excretory organs (Hunner's ulcer, bladder, constipation,
proctalgia fugax, itching anus); in the generative organs
(frigidity, menstrual irregularities and discomforts); in the head
(insomnia, faintness, epilepsy, stroke, migraine, stiff neck).
Stress, in the medical sense, therefore, is any stimulus or succession of stimuli of such magnitude as to tend to disrupt the
homeostasis of the organism. When the mechanisms of adjustment fail or become disproportionate or incoordinate, the stress
may be considered an injury, resulting in disease, disability or
death.
The reaction to stress, however, cannot just be fleeting (as in
fright) to produce a permanent pathologic condition. If this were
so, most of mankind would be a mass of disease processes.
Sustained bombardment of nervous stimuli are required for
such abnormal changes. Such changes are not infrequently due
to dysfunction in the endocrine system of the body. This is a
system of so-called ductless glands. They are known as ductless
glands because they empty their secretions into the circulatory
system. For the sake of simplicity it might be said: the pituitary
gland is the master control gland. It is attached to the base of
the midbrain by a stalk, is closely associated with the ganglia
of the autonomic nervous system, and is interlocked with the
autonomic nervous system functionally. The pituitary gland has
many specific secretions which affect all the other endocrine
glands. The anterior portion secretes substances which stimulate
the thyroid, parathyroid, pancreas, breasts, adrenals and gonads.
Lack of these substances might cause a diminished activity of
these organs. The posterior part of the pituitary is said to start
the uterus contracting at the end of pregnancy causing the delivery of the baby.
The thyroid gland in the neck controls the metabolic rate
of the body. In other words it regulates the fire in the furnace of
the body. The pancreas regulates the amount of sugar available
to be burned in the furnace. The adrenal glands are the glands
of stress. Increased amounts of epinephrine are secreted into
the blood stream when it appears that the fire in the furnace is
likely to be extinguished. If the threat remains too long,
cortisone from the adrenals bring up the reserves for the long
haul.
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It becomes evident that the human body is a complex mechanism with a highly integrated system of defense for self-preservation homeostasis. The interactions between the several nervous
systems and endocrine glands are a series of checks and balances.
When in perfect running order, the happy, healthy human results. When disarranged, the human becomes a functionally
and/or organically diseased wreck. The mechanisms initiating
such disarrangement vary from infectious and metabolic diseases
to mechanical injury. The body reacts to all in a like manner.
The principal aim of this control mechanism is homeostasis or a
normally functioning system. Any disease or injury initiates one
of the compensating homeostatic mechanisms so that the body
returns to normal.
Examples of Psychosomatic Disease
A review of a few of the most common psychosomatic
diseases will illustrate these many pages of introduction. As a
case illustrates a particular point of law, so in medicine the case
illustrates the particular disease.
Stomach
Peptic or gastric ulcer is one of the most common stress or
psychosomatic diseases. Most of us are familiar with the antacids
available without prescription at the drugstore. The dyspeptic
executive worships at the shrine of these proprietaries. He knows
that when the going gets tough and the belly is burning, "antacids" give temporary relief. But he may learn, as many have,
that in long-continued stress, relief by these agents becomes less
and less effective. He soon becomes aware of more serious
symptoms. He might vomit blood or experience excruciating
abdominal pain. Now, the simple stress symptoms of burning
becomes bleeding-a functional discomfort has become an organic disease. Instead of simple increased acidity, the stomach
is now ulcerated. The complicated homeostatic mechanism has
worked so well that a pathologic disease resulted!
Of all the psychosomatic diseases, gastric ulcer is best documented because the stomach is so easily studied. Most doctors
are familiar with Beaumont's studies of Alexis St. Martin, an
Indian who had a gunshot wound of the abdomen. A fistula
(opening) formed whereby the stomach could be watched
through a hole in the abdomen. Through this portal, Beaumont
first watched digestion in the human stomach and his findings
were the basis of gastric physiology for decades.
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More recently, however, Wolf and Wolff studied gastric
functions in a fiery, ill-tempered Irishman named Tom. Tom,
when a young boy, stole a swallow of what he thought to be
beer. The "beer," however, turned out to be very hot clam
chowder. When he swallowed it, the clam chowder burned his
esophagus and the boy was no longer able to swallow food or
liquid. An artificial opening from the skin of the abdomen into
the stomach was made. A gastrostomy was necessary for feeding. Food then could be introduced directly into the stomach.
The study of Tom's stomach during emotional storms is the
basis of much of our gastric physiology today.
When Tom thought of delicious, appetizing food, the walls
of the stomach became redder and the gastric juices were
secreted. Sudden fear, however, caused the walls of the stomach
to blanche and secretion of gastric juices to stop. This is the
emotion of flight and fear. Sadness and other such feelings also
were found to be marked by a depression of these gastric functions. However, increased function of the stomach was produced by the emotions involving conflict, hostility, resentment,
and anxiety. Wolf and Wolff in their book, Gastric Changes
Accompanying Emotion, state "Profound alterations in gastric
function as well as in other bodily patterns were found to accompany emotional disturbance. The alterations in gastric function fall into two categories: (1) depression of acid output,
motor activity and vascularity, and (2) acceleration of these
functions. The former was associated with a reaction of flight
or withdrawal from an emotionally charged situation. The latter
accompanied a reaction of internal conflict, with an unfulfilled
desire for aggression and fighting back. Profound and prolonged
emotional disturbances of this kind were accompanied by marked
and prolonged increases in gastric motility, secretion, and
vascularity with reddening and engorgement of the mucous
membrane, ofter reproducing the picture of gastritis.
Accelerated acid production and motor activity are always
accompanied by engorgement of blood vessels of the lining of
the stomach. When engorgement is prolonged, the walls become intensely red, thick and turgid, presenting the picture of
what has been called "hypertrophic gastritis." In this state the
mucosa is unusually fragile, bleeds easily, and small erosions
result from minor injuries. Lowering of the pain threshold occurs and symptoms are often associated with this condition.
Thus the difference between hyperfunction in the stomach and
hypertrophic gastritis is seen to be mainly one of degree. Con-
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tinued exposure to the digestive action of gastric juice for four
days results in peptic ulcer. Thus in long-continued periods of
stress, normal stomach reflexes can become pathologic with the
production of diseased states. The continued reaching for an
"antacid" to relieve the acid indigestion has become a habit, but
the results of such medication are diminishing. The pain persists
in spite of therapy. A fleeting case of indigestion has progressed
through hypertrophic gastritis to gastric ulceration. A true
pathologic condition has resulted from emotional stress or wear
and tear. This is known as the "American Disease" and constitutes a major portion of every physician's practice.
Menses
One of the more common manifestations of stress in women
is the affection of the menses. Stress may be manifested in any
one or combination of the following: amenorrhea-cessation of
the menses; irregular menstruation; menorrhagia-excessive
flow; or dysmenorrhea-pain during periods. The latter condition has been the subject of a great amount of writing both in
this Law Review and in many medical journals. Authors have
attempted to classify dysmenorrhea according to cause. The
simplest classification is that by Wittkower and Cleghorn. The
first group is constituted by those women to whom the onset of
the flow constitutes the signal for a hysterical reaction. These
women exaggerate all the feelings that every normal woman
experiences during a menstrual period. It is the typical hysterical reaction of weakness, collapse, indescribable pain, amnesia,
etc. The reaction may be massive enough to interrupt normal
life for a period of a day or two.
Other women may have dysmenorrhea as a result of or as
a reaction to stress. Usually the abnormal periods begin after
the woman has experienced an emotional bout or has suffered
feelings of insecurity. The patient usually is anxious or depressed, and the pain becomes severe. The flow may also be
accompanied by other distressing conditions, such as flooding
or nausea and vomiting. Frequently, one of the most invaliding
symptoms is the migraine-type headache. This distressing combination of conditions may be so overwhelming as to cause the
woman to be prostrate for one or more days.
If these symptoms are present when her menstrual cycle
starts (menarche), the girl usually has lived in a setting of insecurity or family strife.
The second classic group of dysmenorrhea is found in the
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Atalanta syndrome.* Dysmenorrhea is one of the Atalanta
symptoms and some of the most severe forms of dysmenorrhea
are met within women whose overt behavior and mental content
show that they are repudiating the female role.
Dysmenorrhea occurs in two different types of personalities.
One group is distinguished by resentment of the female role.
The women are hard and aggressive in expression, with unfeminine voices and masculine carriage. As children they were
tomboys, fond of rough games and often outstanding at school.
They usually are resentful of menses. They like to remain
sisters to their men friends, and in feminine fields display a hard
emotional inaccessibility, which often covers a rebellion against
their own nature.
The other main group have small juvenile faces and fragile
physiques. They are shy and timid, menstruation to them is
an affront to their high standards of fitness and personal cleanliness.
Heart
Many symptoms of the emotional states are manifested in
changes in the circulatory system. In fright, the heart skips a
beat or pounds in the chest. Others describe the heart as racing
or as "in their mouths." So definite and striking are these
phrases and descriptions that the syndrome is recognized by almost everyone. The question then arises: "Can this reaction in
a diseased heart produce permanent damage?"
The heart in the human is not only a complex pump mechanism but its nervous control is still not fully understood. However, the heart works with great efficiency and has a great
amount of reserve. If normal at birth, the reserve steadily declines throughout life until it reaches the stage where the requirements for life demands the full cardiac output.
Stress reactions cause a quickening of the pulse, increased
cardiac output and increased blood pressure. These are the
heart's methods of meeting the requirements of the emergency.
When the person is alarmed, the homeostatic mechanism com* Atalanta, a heroine, beautiful and fleet of foot. In Boetian legend she
challenges her suitors to a race, death being the penalty of defeat, and her
hand the prize of victory. Hippomenes defeats her, dropping on the course
three golden apples, given to him by Aphrodite, which Atalanta stoops to
pick up.
Atalanta symptoms are: frigidity, dyspareunia, dysmenorrhea, irregular
menstruation, amenorrhea, menorrhagic abortion or miscarriage, vomiting
in pregnancy, difficult labor, minor illness or depression and failure of lactation in puerperium.
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pensates to protect the whole body. Cannon contended that additional epinephrine is secreted. The blood vessels in the brain
and coronary vessels of the heart dilate. This provides an increased amount of blood to the brain and heart. Many other
vessels contract in order to economize in the areas where increased energy is not needed.
Whenever the body reacts to these situations, there is an
increased strain on the heart and vessels of the body. The heart's
work now increases many times. It must not only pump a greater
amount of blood through the circulatory system but it must
pump it at greater pressures and against greater peripheral resistance. The normal heart can cope with these situations with
great ease. However, the aging heart may show signs of infirmity. The coronary vessels may be sclerosed sufficiently so
that the increased work load may be too great. In such a case,
the oxygen being delivered to the heart muscle by the blood
pumped through the coronary arteries may be insufficient. The
heart muscle will then react violently with pain and irregularity.
If continued, of course, this will result in myocardial ischemia and
possibly in cardiac standstill.
These conditions have been thoroughly studied in countless
investigations. The physician today has innumerable diagnostic
machines to determine the state of the myocardium. In fact,
today, much investigation is taking place in the treatment of
these cardiac diseases.
The important fact remains that everyone has a diminishing
cardiac reserve. The vessels of the heart are constantly becoming
less elastic and more sclerotic. This process progresses at different rates in various individuals. Some aged persons have
relatively young coronary vessels. We all have had friends who
died of coronary vascular disease at relatively young ages. In
these, the aging process or hardening process progressed out of
all proportion to the chronologic age. One can readily understand that increased pressure, worry, or anxiety might readily
produce a strain on this individual's heart out of all proportion
to that in another his own age. Perhaps this is the reason why
physicians and lawyers die young and why industry carries huge
amounts of life insurance on its executives.
Conclusion
Psychosomatic medicine, like equity, cuts across the whole
of medicine. It deals with the relation of the psyche to the soma.
To understand the field, one must comprehend at least the funda-
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mentals of all the rest of the body. No organ or system is exempt. In this article, the three specific discussions serve to illustrate psychosomatic disease in three different areas of the
body. There are countless other psychosomatic diseases. It can
readily be seen that emotional drive or stress can exert somatic
responses which are physiologic. If of great intensity or prolonged, the reaction in the body becomes pathologic and a disease process results. When such a state is reached, removal of
the stress may not be sufficient. The disease process already is
present. If it does not regress spontaneously, other therapeutic
measures may be indicated.
The whole sequence of events has been precipitated by an
organic injury or mental stress. These stimuli cause the reactions carried through the autonomic nervous system. Each
individual responds in his own particular manner. Some of us
have severe diarrhea from stimulation of the small gut, when
worried. If continued, the horrible disease of regional enteritis
may ensue. Others get migrane headaches. Although uncomfortable and perhaps incapacitating, serious sequelae are not
known. The more fortunate person gets some simple, not incapacitating condition, such as proctalgia fugax. This condition
is manifested as a spasmodic pain in the rectum. These persons
and the dysmenorrheic woman can count themselves among the
fortunate when they compare their inconsequential infirmity
with some of the serious and frequently fatal psychosomatic diseases, such as ileitis, gastric ulcer, and coronary artery disease.
* In a summarizing paper before the Association of American Physicians,
Wolff gave this remarkable epitome: "Interference with or threat to his
life or love, or blocking the proper fulfillment of an individual's potential,
causes him to react as though to assault. He responds defensively or offensively, or both, depending on his nature, his past experience, and the situation. Under these circumstances he struggles to regain what has been lost
and to rid himself of interference, in order to fulfill his drives. Such
struggles evoke what may be called emergency or crisis protective patterns.
"A considerable part of the human equipment has to do with meeting
emergencies and dealing with crises. Protective reactions are set off by
threats usually in the form of symbols, which have been connected with
danger in the past.
"Some of these reactions represent widespread mobilization to provide
extra fuel and energy for vital parts of the organism. Others appear to be
focused on regional defenses, notably at portals of entry and exit. Offensive and defensive, general and local protective devices may operate together and separately.
"Along with these conspicuous bodily preparations go certain feelings
and attitudes which, stemming from the same needs, have the same goals.
"The organism sacrifices at such times some functions or capacities for
the sake of promoting others that are most important to meet the adverse
situation. Although there is a degree of specialization in the sense that one
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or another protective arrangement is dominant, discrimination is not exact.
In a threatened man it is common to find a variety of protective reactions,
some of which are extremely pertinent, others less so, and still others
minimally effective.
"Because his drives are primitive and even violent, they may be out of
keeping with a man's conception of himself and therefore unacceptable.
Thus, the drive denied or not fully recognized by the subject, the subsequently evoked protective reaction patterns may unwittingly become sustained. A few of these reaction patterns have been intensively studied.
"During assaults or threats arousing conflict, with anger and a pattern of
offense, the stomach prepares itself for eating with increased blood flow,
acid secretion and motility. The gastric mucosa may become turgescent
and the blood vessels friable. With forceful gastric contractions, bleeding
readily ensues and erosions of the mucous membrane may follow.
"In reactions to assaults, threats, or symbols arousing conflicts changes
with resentment and hostility a protective pattern of defense involving the
large bowel may precipitate a disastrous chain of events. The colonic
mucosa may become engorged, turgid, and myriads of petechial hemorrhages ensue. With violent contractions increased concentrations of mycolytic enzymes and increased fragility of the mucous membrane, this membrane may erode and ominous hemorrhage ensue.
"Conspicuous among defensive protective reactions are those involving
the nose and airways. It has been observed that in reaction to assault, certain individuals occlude their air passages and limit the ventilatory exchange by vasodilation, turgescence, hypersecretion, and smooth and skeletal
muscle contractions. The changes, especially in the upper respiratory airways give rise to a variety of symptoms, notably pain and obstruction, the
latter often leading to secondary infections and the prolongation of morbid
processes. Also, a non-participation behavior pattern and attitude is exhibited in interpersonal relations.
"Offensive protective reactions involving chiefly the cardiovascular and
renal systems were exhibited in certain aggressive individuals. These persons, in reaction to assault, mobilized their equipment, causing the work
of the heart to be greatly increased through increased rate, output and
peripheral resistance. Especially notable in those with pressor reactions and
essential hypertension was a significant reduction in renal flow during
periods of experimentally induced assault, an effect with potentially ominous implications.
"It is suggested that when the individual maintains such emergency
measures symptoms and tissue damage may follow.
"In brief, man, feeling threatened, may use for long-term purposes,
devices designed for short-term needs. Costly protective activities are
essential and life-saving. They are devised for fleeting emergencies so that
he may destroy those forces that threaten his survival. But, they are not
designed to be used as life-long patterns and when so utilized, may damage
structures they were devised to protect.
"These considerations constitute the basis of a good deal of human suffering and sickness. To prevent these disorders more knowledge concerning
the origin of these patterns in childhood is necessary. To interrupt them
once they have become well established requires a vigorous and fresh approach. To deal with these disturbances it is necessary to study the functions of organs widely separated in the body, and because the methods require cutting across the lines which usually separate the various medical
skills, the horizon of the physician must be broadened. It follows that
interest in these illnesses cannot be limited by delineations of a new
specialty of medicine. The pursuit of these matters is a prime medical
responsibility of our day."
Wolff, Harold: Emotional and Clinical Medicine. Cobb
W. W. Norton & Company, New York, 1950.
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Causation of the many psychosomatic diseases has been
generally established and accepted in medicine today. However,
the yardstick for measuring such cause and effect for any one
complex has not yet been developed. As stated many times,
medicine is not an exact science. It does not progress as a given
formula of reaction in chemistry or a given sequence in the field
of physics. Instead the human is a complex set of interacting
systems, more or less under the central control of the brain but
modified in some situations by autonomy of the individual organs
or glands. The personality of each human is unique. Therefore,
any given external stimuli will not cause the same reaction in
any of us. However, the general pattern of stress has been described and accepted by most medical authorities. The acute
period of stress calls into play emergency reflexes to protect the
body in these stressed conditions. If, however, this emergency
of stress persists, the body may not have capacity to withstand
these pressures. At this point, a normal protective reflex becomes an abnormal pathologic disease. There are numerous
cases in tort law where damages are not allowed for mental pain
and suffering when no contact is proved. Yet, by the above
series, it is clearly shown and accepted that an organic reaction
to an emotional problem is one of the most common diseases in
the practice of medicine.
The problem of proof is difficult. In this field, medicine lags.
As yet there are no specific laboratory tests. Probably the closest
yet has been the stress lymphocyte and the eosinopenia of stress
(Wasmuth). However, these lack specificity and certainly cannot be held as quantitative examinations. The problem then resolves itself around one statement acceptable to both professions:
Stress diseases are clinical entities, the cause is known but the
measuring sticks not yet adequate. Causation can be proved by
the existence of the disease as detected by innumerable diagnostic aids. To assess the extent of damages accurately becomes
a problem to be solved in the medical laboratory. But in the
meantime, the law must accept the causation.
BIBLIOGRAPHY
Alexander, F., and Menninger, W. C. "Relation of persecutory delusions to
functioning of gastrointestinal tract." 84 J. Nerv. & Ment. Dis. 541 (1936).
Henry, G. W. "Some roentgenologic observations of gastrointestinal conditions associated with mental disorders." 3 Am. J. Psychiat. 681 (1924).
Moersch, F. P. "Psychic manifestation of migraine." 3 Am. J. Psychiat. 697
(1924).
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Szasa, T. S. "Psychoanalysis and autonomic nervous system." 30 Psychoanalyt. Rev. 115 (1952).
Cobb, Stanley "Emotions and Clinical Medicine," New York, W. W. Norton
& Co., 1951.
Cobb, Stanley "On nature and locus of mind." 67 Arch. Neurol. 172 (1952).
Wolf, S., and Wolff, H. G. "Human Gastric Function, An Experimental
Study on a Man and His Stomach," New York, Oxford Press, 1947.
Gellhorn, E., Cortell, R., and Feldman, J. "Autonomic basis of emotions."
92 Science 288 (1940).
Penfield, W. G., and Rasmussen, T. "The Cerebral Cortex of Man," New
York, The Macmillan Company, 1950.
Donovan, J. C. "Menopausal syndrome," 62 Am. J. Obst. & Gynec. 1281
(1951).
O'Neill, D. "Incidence of Atalanta symptoms." 27 Postgrad. Med. 468 (195i).
Kroger, W. S., and Freed, S. C. "Psychosomatic Gynecology," Philadelphia,
W. B. Saunders Co., 1951.
Bertling, M. H. "Some psychic aspects of dysmenorrhea and nausea and
vomiting," 56 Am. J. Obst. & Gynec. 733 (1948).
Dunbar, H. F. "Emotions and Bodily Changes," New York, Columbia University Press, 1946.
Menninger, K. "Somatic correlations with unconscious repudiation of
feminity in women." 89 J. Nerv. & Ment. Dis. 514 (1939).
Wittkower, E. D., and Cleghorn, R. A. "Recent Developments in Psychosomatic Medicine," Philadelphia, J. B. Lippincott Co., 1954.
Weiss, Edward, and English, 0. Spurgeon "Psychosomatic Medicine," Philadelphia, W. B. Saunders Co., 1957.
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